Phimosis

from Wikipedia, the free encyclopedia
Erect penis with phimosis
Classification according to ICD-10
N47 Foreskin hypertrophy, phimosis and paraphimosis
ICD-10 online (WHO version 2019)

The phimosis (from ancient Greek φῑμός phimos "narrowing") or phimosis is a narrowing of the opening of the foreskin of the penis . As a result, the foreskin cannot be pulled back behind the glans , or only with pain .

With regard to the cause, a distinction is made between two types of phimosis: 1) Physiological phimosis, also congenital (congenital) phimosis or primary phimosis , is the natural adhesion of the foreskin to the glans and occurs in about 96% of newborn boys due to development, but resolves usually in childhood or early adolescence. In persistent cases, an originally primary phimosis is considered a pathological phimosis .

2) Pathological ("pathological") phimosis is a permanent narrowing of the foreskin, so that it can no longer be pulled back and forth completely over the glans without pain and injury, and medical treatment is therefore indicated. In pathological phimosis , a distinction can also be made in terms of shape between complete phimosis and incomplete phimosis . If the foreskin cannot be brought back over the glans even when the penis is flaccid, it is called a complete phimosis . With incomplete phimosis , retraction of the foreskin is difficult only if the penis is erect , and there is a risk of paraphimosis .

Phimosis can also occur for the first time or again at a later age due to decreased skin elasticity or scars from injuries or inflammation. Here one speaks of an acquired phimosis or secondary phimosis .

Physiological phimosis

The clinical picture phimosis must be distinguished from the developmentally non-retractable penile foreskin.

At birth , the foreskin is glued to the glans to protect the sensitive glans from harmful environmental influences. This “physiological phimosis”, also known as preputial adhesions , can be assumed in 96% of untreated newborn boys. Physiological phimosis usually resolves in childhood or early adolescence.

Very rarely does it take beyond the age of 17 before the foreskin has detached from the glans and can be completely pulled back. In a 1996 study of 603 Japanese boys between the ages of 0 and 15, it was found that 63 percent of the boys examined between the ages of 11 and 15 had completely retractable foreskin. In another study of 242 Japanese boys in 2004, the foreskin was retractable in 77 percent of the subjects at this age group. In a study of 1200 Cuban boys between the ages of 0 and 16 years in 2008, 11-16 year olds only had a non-retractable foreskin in 0.9 percent of the cases, whereas in 81 percent of the cases a completely retractable foreskin was found Foreskin in front. In 1968, a study of Danish schoolboys between the ages of six and 17 found that one percent of boys between the ages of 16-17 years had phimosis and three percent had preputial adhesions.

Pathological phimosis

An uncircumcised penis with phimosis

A pathologic phimosis is when as a result of fibrosis or scarring of the foreskin is impossible -Öffnung, the foreskin injury-free over the glans ( glans penis withdraw).

Side symptoms that may indicate pathological phimosis are:

  • Recurrent inflammation of the glans penis and / or foreskin. Such recurring inflammations can lead to phimosis in patients with type 2 diabetes in particular .
  • Reduced strength and deviating direction of the urine stream, possibly bloating of the foreskin
  • Sustainable urine congestion
  • Painful urination
  • A whitish ring of hardened scar tissue that forms on the tip of the foreskin, called scar phimosis , caused by chronic balanitis xerotica obliterans (BXO) , a skin disease of as yet unexplained origin. The whitish inelastic ring makes it difficult to pull back the foreskin.

Recurring inflammation of the narrowed foreskin leads to the aforementioned scarred changes. Furthermore, sudden attempts at retraction cause tears with subsequent phimosis that is fixed in the form of secondary scarring. A lichen sclerosus et atrophicus , the first to a bonding and then to sclerotic shrinkage and thereby narrowing of the foreskin leads is partially genetically determined.

Paraphimosis

Phimosis with retracted foreskin

→ Main article: Paraphimosis

Paraphimosis, also known as the “Spanish collar”, describes a urological emergency in which the forcefully withdrawn, constricted foreskin pinches the glans penis . There is a disruption of the blood flow and painful swelling of the foreskin and glans. If the edema cannot be removed with pressure and gentle massage, a doctor should be consulted immediately. Under local anesthesia, this can either successfully pull the trapped foreskin back over the glans into the normal position without blood, or otherwise split it surgically (dorsal incision) in order to prevent acute damage to the glans due to insufficient blood flow. If not treated, there is a risk of loss of the glans as well as severe pain due to gangrene formation .

treatment

According to current medical standards, two main methods are available for the treatment of phimosis: conservative (non-surgical) and surgical treatments. Research efforts in recent years make it clear that conservative measures can be very inexpensive and effective.

Conservative treatment is always preferable to surgery. Surgical treatment should only be considered if non-surgical therapy has failed. Esposito et al. For phimosis from grade 0 to II (the foreskin can be pulled back completely or up to half of the glans penis) do not perform any treatment and for grade III – V phimosis (only the urethra is visible or the foreskin can no longer be seen at all) should be withdrawn) to resort to conservative treatment methods (treatment with ointments containing steroids). Only when conservative treatment attempts have failed, according to Esposito et al., Should an operation be considered.

Conservative treatment

The so-called conservative, ie non-surgical treatment includes the stretching of the phimosis or the loosening of the adhesive by carefully moving the foreskin - as far as this is possible painlessly and without resistance - while applying corticoid-containing ointment preparations. This measure is carried out over a longer period of time and, if carried out properly, has no side effects (see Esposito et al.); in particular, it is not an intervention that is difficult to reverse. According to the German Society for Urology, the success rate for the conservative treatment of phimoses with ointment preparations is between 50 and 75 percent, and according to recent medical studies even higher. Due to their cost-benefit balance, conservative procedures are suggested today as the method of choice for treating phimosis.

Operative treatment

Indications for surgical treatment of phimosis are:

Relative indications for a possible but not absolutely necessary surgical treatment are:

Prepuce

Enlargement of the foreskin

A prepuce plasty or foreskin plasty is a surgical method in which the foreskin is completely preserved. This results in a cosmetically good surgical result and complete preservation of the foreskin. The basic principle of many of these foreskin sculptures consists of one or more small longitudinal incisions ( incisions ) and the subsequent cross-stitching of the wound defects. A distinction is made between different surgical procedures:

  • Dorsal incision with transversal closures : With this surgical technique, a small incision is made lengthways through the stenotic (narrowing) ring and is then sutured transversely (transversely closed).
  • Lateral prepuce plasty : The lateral prepuce plasty represents a small refinement of the dorsal incision with a transverse closure. Two small lateral longitudinal incisions are made and then cross-stitched.
  • Triple Incision : The Triple Incision is a method of foreskin enlargement. Under local or general anesthesia, three small longitudinal incisions are made in the foreskin, which are stretched to the required width and then sutured again.

If surgery becomes unavoidable after an unsuccessful stretch therapy with a corticoid-containing ointment, prepuceoplasty is always preferable to classic circumcision because of its lower morbidity , lower complication rate and lower costs.

  • Example: Surgery to preserve the foreskin

  • Phimosis in a boy, before surgery

  • The narrowed area

  • Incision in the skin

  • The bleeding is stopped by thermal coagulation

  • Six months after surgery with the foreskin pulled back

  • Six months after the operation with the foreskin closed

  • A Foreskin Retraction Series.JPG

Circumcision

In circumcision , the foreskin is either completely removed (radical circumcision) or only the narrowed anterior part of the foreskin is resected (partial circumcision), depending on medical necessity, if necessary with the inclusion of cosmetic aspects or the wishes of the patient or his or her guardian . Circumcision is indicated in severe cases of pathological phimosis, in which both non-surgical therapy with ointment containing cortisone and prepuceplasty that preserves the foreskin are primarily unsuccessful (for example, in chronic balanitis xerotica obliterans) or have previously failed to cure.

Complications of operative procedures

Circumcisions have a significant complication rate; this concerns secondary bleeding, wound healing disorders, edema formation and meatal stenosis . The specific risk of partially resecting or foreskin-preserving procedures lies in the possibility of scarred recurrence phimoses. If the cosmetic appearance is unsatisfactory, for example due to the asymmetry or length of the foreskin remnant, reoperations may be necessary.

Shortened foreskin ligament ( frenulum breve )

In addition to the narrowing of the foreskin, a shortened foreskin ligament can also cause difficulties when pulling back the foreskin. One then speaks of the frenulum breve .

literature

Web links

Commons : Phimosis  - collection of images, videos and audio files
Wiktionary: Phimosis  - explanations of meanings, word origins, synonyms, translations

Individual evidence

  1. ^ Wunna Lippert-Burmester, Herbert Lippert: Medical terminology made easy: textbook and workbook . Schattauer, Stuttgart / New York 2008, ISBN 978-3-7945-2644-4 ( google.de [accessed October 10, 2019]).
  2. ↑ a b Karin Janke, Claudia Krallmann, Arne Tiemann: Phimosis (foreskin narrowing) . On: urologenportal.de of November 23, 2006, updated August 8, 2016; last accessed on August 13, 2016.
  3. ↑ Willibald Pschyrembel: Clinical dictionary: with clinical syndromes and nomina anatomica . 254th, revised edition, de Gruyter, Berlin / New York 1982, ISBN 3-11-007187-8 , p. 919 (keyword phimosis ).
  4. ↑ a b c d e f g h i S1 guideline Phimosis and Paraphimosis of the German Society for Pediatric Surgery (DGKCH). In: AWMF online (as of August 2013)
  5. ↑ Clinic and Polyclinic for Pediatric Surgery at the Charité, Berlin: Phimosis ( Memento from August 14, 2016 in the Internet Archive )
  6. ↑ Hiroyuki Kabaya, Hiromi Tamura, Seiichi Kitajima, Yoshiyuki Fujiwara, Tetsuo Kato, Tetsuro Kato: Analysis of shape and retractability of the prepuce in 603 Japanese boys . In: The Journal of Urology . Volume 156, No. 5, November 1996, pp. 1813-1815. doi : 10.1016 / S0022-5347 (01) 65544-7 . PMID 8863623 .
  7. ^ E. Ishikawa, M. Kawakita: Preputial development in Japanese boys. In: Hinyokika Kiyo. May 2004, Volume 50, Number 5, pp. 305-308, PMID 15237481 .
  8. Jump up ↑ JC Concepción, PG Fernández, AM Aránegui, MG Rodríguez, BM Casacó: The need of circumcision or prepuce dilation. A study with 1200 boys. In: Archivos españoles de urología. (Arch Esp Urol.) July-August 2008, Vol. 61, No. 6, pp. 699-704. PMID 18705191 . ( PDF full text. )
  9. ↑ Jakob Oster: Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys . In: Arch. Dis. Child. . 43, No. 228, 1968, pp. 200-203. doi : 10.1136 / adc.43.228.200 . PMID 5689532 . PMC 2019851 (free full text).
  10. ^ CW Laymon, C. Freeman: Relationship of Balanitis Xerotica Obliterans to Lichen Sclerosus et Atrophicus . In: Arch Dermat Syph . 49, 1944, pp. 57-59.
  11. ↑ a b c C. Esposito, A. Centonze, F. Alicchio, A. Savanelli, A. Settimi: Topical steroid application versus circumcision in pediatric patients with phimosis: a prospective randomized placebo controlled clinical trial. In: World Journal of Urology. ( World J Urol .) Vol. 26, 2008, pp. 187-190, PMID 18157674 .
  12. ↑ N. Zampieri, M. Corroppolo, V. Zuin, S. Bianchi, FS Camoglio: Phimosis and topical steroids: new clinical findings. In: Pediatric Surgery International. (Pediatr. Surg. Int.) Vol. 23, 2007, pp. 331-335, PMID 17308904 .
  13. ↑ a b c MedReview, edition 12/2004, page 10
  14. ↑ a b c E. Yilmaz, E. Batislam, MM Basar, H. Basar: Psychological trauma of circumcision in the phallic period could be avoided by using topical steroids. In: International Journal of Urology. (Int. J. Urol.) Vol. 10, 2003, pp. 651-656, PMID 14633068 .
  15. ^ JE Ashfield, KR Nickel, DR Siemens, AE MacNeily, JC Nickel: Treatment of phimosis with topical steroids in 194 children. In: The Journal of urology. Volume 169, Number 3, March 2003, pp. 1106-1108, ISSN  0022-5347 . doi : 10.1097 / 01.ju.0000048973.26072.eb . PMID 12576863 .
  16. ↑ PM Cuckow, G. Rix, PD Mouriquand: Preputial plasty: a good alternative to circumcision. In: Journal of pediatric surgery. Volume 29, Number 4, April 1994, pp. 561-563, ISSN  0022-3468 . PMID 8014816 .
  17. ↑ D. Berdeu, L. Sauze, P. Ha-Vinh, C. Blum-Boisgard: Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect. In: BJU International . Volume 87, Number 3, February 2001, pp. 239-244, ISSN  1464-4096 . PMID 11167650 . (Review).
  18. ^ A b A. K. Saxena, K. Schaarschmidt, A. Reich, GHWillital: Non-retractile foreskin: a single center 13-year experience . In: Int Surg . 85, No. 2, 2000, pp. 180-3. PMID 11071339 .
  19. ^ A b R. S. Van Howe: Cost-effective treatment of phimosis. In: Pediatrics. Volume 102, Number 4, October 1998, pp. E43, ISSN  1098-4275 . PMID 9755280 . (Review).
  20. ↑ PDF Medical Tribune 11/2000 "Three cuts save the foreskin" ( Memento of the original from December 14, 2013 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / extranet.medical-tribune.de
  21. ↑ CH Fischer-Klein, M. Rauchwald: Triple incision to treat phimosis in children: an alternative to circumcision? In: BJU international. Volume 92, Number 4, September 2003, pp. 459-462, ISSN  1464-4096 . PMID 12930440 .
  22. ↑ E. Christianakis: sutureless prepuceplasty with wound healing by second intention: An alternative surgical approach treatment in children's phimosis. In: BMC Urology. Volume 8, 2008, p. 6. doi : 10.1186 / 1471-2490-8-6 PMID 18318903 ( Open Access )
  23. ^ N. Williams, L. Kapila: Complications of circumcision. In: British Journal of Surgery . No. 80, 1993, pp. 1231-1236. PMID 8242285 full text